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Palliative Management Of: • Nausea And Vomiting • Dyspnea • Secretions • Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor, University of Manitoba Faculty of Medicine MECHANISM OF NAUSEA AND VOMITING • vomiting centre in reticular formation of medulla • activated by stimuli from: – Chemoreceptor Trigger Zone (CTZ) • area postrema, floor of the fourth ventricle • outside blood-brain barrier (fenestrated venules) – Upper GI tract & pharynx – Vestibular apparatus – Higher cortical centres Cortex CTZ GI VOMITING CENTRE Vestibular Stimuli Of Vomiting Pathways Chemoreceptor Trigger Zone drugs • opioids • chemoTx • etc... biochemical • Ca++ • renal failure • liver failure sepsis radiotherapy Vestibular tumor opioids Cortical anxiety association Peripheral radiotherapy chemotherapy ICP GI irritation • inflammation • obstruction • paresis • compression PRINCIPLES OF TREATING NAUSEA & VOMITING • Treat the cause, if possible and appropriate • Environmental measures • Antiemetic use: – anticipate need if possible – use adequate, regular doses – aim at presumed receptor involved – combinations if necessary – anticipate need for alternate routes Stimulus Area Drugs, Metabolic Chemoreceptor trigger zone Motion, Position Vestibular Organs ? Nonspecific CNS ↑ ICP Cerebral cortex Dopamine D2 5HT 5HT Visceral D2 Receptors 5HT H1 Serotonin Histamine M H1 H1 M D2 5HT VOMITING CENTRE CB1 H1 M Muscarinic Effector Organs CB1 Cannabinoid From: Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice Arch. Dis. Child. 2004;89;877-880 E S Antonarakis and R D W Hain Dyspnea In Palliative Care DYSPNEA: An uncomfortable awareness of breathing DYSPNEA: “...the most common severe symptom in the last days of life” Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 - 98 Approach To The Dyspneic Palliative Patient Two basic intervention types: 1. Non-specific, symptom-oriented 2. Disease-specific Simple Non-Specific Measures In Managing Dyspnea • calm reassurance • patient sitting up / semi-reclined • open window • fan Non-Specific Pharmacologic Interventions In Dyspnea • Oxygen - hypoxic and ? non-hypoxic • Opioids - complex variety of central effects • Chlorpromazine or Methotrimeprazine some evidence in adult literature; caution in children due to potential for dystonic reactions • Benzodiazepines - literature inconsistent but clinical experience extensive and supportive TREAT THE CAUSE OF DYSPNEA IF POSSIBLE AND APPROPRIATE • Anti-tumor: chemo/radTx, hormone, laser • Infection • Anemia • CHF • SVCO • Pleural effusion • Pulmonary embolism • Airway obstruction DISEASE-SPECIFIC MEDICATIONS FOR DYSPNEA • Corticosteroids – obstruction: SVCO, airway – lymphangitic carcinomatosis – radiation pneumonitis • Furosemide – CHF – lymphangitic carcinomatosis • Antibiotics • Anticoagulation – pulm. embolus • Bronchodilators • Transfusion Opioids in Dyspnea Uncertain mechanism Comfort achieved before resp compromise; rate often unchanged Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration Dosage should be titrated empirically; may easily reach doses commonly seen in adults May need rapid dose escalation in order to keep up with rapidly progressing distress A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS How do you know that the aggressive use of opioids for pain or dyspnea doesn't actually bring about or speed up the patient's death? SUBCUTANEOUS MORPHINE IN TERMINAL CANCER Bruera et al. J Pain Symptom Manage. 1990; 5:341-344 100 90 80 Pre-Morphine 70 Post-Morphine 60 50 40 30 20 10 0 Dyspnea Pain Resp. Rate (breaths/min) O2 Sat (%) pCO2 Typically, with excessive opioid dosing one would see: • pinpoint pupils • gradual slowing of the respiratory rate • breathing is deep (though may be shallow) and regular COMMON BREATHING PATTERNS IN THE FINAL HOURS Cheyne-Stokes Rapid, shallow “Agonal” / Ataxic Palliative Management of Secretions Secretions - Prevalence At Study Entry And In Last Month Of Life UK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey Goldman A et al; Pediatrics 2006; 117; 1179-1186 45 40 Any 35 Major Problem 30 25 20 15 10 5 0 Study Entrance Last Month Managing Secretions in Palliative Patients Factors influencing approach management: Oral secretions vs.. lower respiratory Level of alertness and expectations thereof Proximity of expected death “Death Rattle” – up to 50% in final hours of life At times the issue is more one of creating an environment less upsetting to visiting family/friends Suctioning: “If you can see it, you can suction it” Suctioning Increased Secretions Mucosal Trauma CONGESTION IN THE FINAL HOURS “Death Rattle” • Positioning • ANTISECRETORY: Scopolamine, glycopyrrolate • Consider suctioning if secretions are: distressing, proximal, accessible not responding to antisecretory agents Atropine Eye Drops For Palliative Management Of Secretions • Atropine 1% ophthalmic preparation • Local oral effect for excessive salivation/drooling • Dose is usually 1 – 2 drops SL or buccal q6h prn • There may be systemic absorption… watch for tachycardia, flushing Delirium in Palliative Care Definition Etiologically non-specific global cerebral dysfunction associated with changes in LOC, attention, thinking, perception, memory, psychomotor behavior, emotion and the sleep/wake cycle DSM-IV Criteria A. Change in consciousness with reduced ability to focus, sustain or shift attention B. Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia C. Abrupt onset (hours to days) with fluctuation D. Evidence of medical condition judged to be etiologically related to disturbance Characteristics Abrupt onset Disorientation, fluctuation of symptoms Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixed Changes in sleeping patterns Incoherent, rambling speech Fluctuating emotions Activity that is disorganized and without purpose Delirium Types Hypoactive – confusion, somnolence, alertness Hyperactive – agitation, hallucinations, aggression Mixed (>60%) – features of both Prevalence of Delirium 20% - 44% on admission to a palliative care unit (common reason for admission) 28% - 45% of patients developed delirium while on the palliative care unit 68% - 90% prior to death Lawlor et al (J Pall Care 1998) – n = 103 pts – 50% of episodes reversible – Terminal delirium in 88% – Hyperactive (5%) vs. hypoactive (47%) – Mixed (48%) most common Delirium versus Dementia Delirium Dementia Abrupt onset Insidious onset Decreased/Fluctuating LOC LOC intact, alert Erratic behaviour Consistent behaviour Sleep/wake cycle change Minimal changes Reversible (theoretically) Irreversible Causes Of Delirium In Palliative Care 1. Tumour • Primary, metastatic, leptomeningeal, paraneoplastic syndrome 2. Metabolic / physiologic • hypercalcemia • Hyponatremia (hypernatremia less commonly) • ↑ or ↓ glucose • anemia, hypoxia • CO2 • Renal or liver failure 3. Infection – UTI, pneumonia, biliary tract, wounds 4. Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory 5. Medication / Drug withdrawal 6. Etc….. Management Of Delirium In Palliative Care 1. Environmental Quite, private setting: single room if possible Low lighting, calendar, clock, familiar objects Minimal room changes with unnecessary distractions 2. Fix the Fixable – if possible and appropriate 3. Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible 4. Effective sedation – with frank discussion of anticipated course If delirium irreversible, goal of care is sedation Sedation does not hasten the dying process Will facilitate meaningful visiting Encourage communication, even though patient not interactive